What’s going on down there? The pelvic exam explained step by step.

What’s going on down there? The pelvic exam explained step by step.

Over the years, as I listen to people, I began to wonder why they seem to be getting so many pap smear tests. I finally figured out that often the words “pap smear” can be synonymous with an internal pelvic or any type of “GYN” exam. So now that I have the opportunity to talk about anything I want that I think may be useful to others, I want to set the record straight.

A pap smear does not equal a pelvic exam and just because you have a pelvic exam does not mean you are having a pap smear test. It may not be surprising, but so many people do not fully understand what happens during a pelvic exam. So here is a detailed guide.

Let’s start from the beginning, really at the beginning, starting with entering the exam room at your provider’s office. After a nurse or medical assistant takes your vital signs and asks you some basic questions, you may be asked to put on a gown or “johnnie” and wait for the provider. Personally I never like to meet a woman naked or in one of those flimsy gowns. I mean, I am fully dressed, so it is only fair. Leaving a women in a cold room on a sterile table, barely dressed sends a message, and since I like to promote partnership, I rather meet a person on equal terms. I like to get a medical history with the person fully clothed, then ask the client to undress and put on a gown or robe when I am not in the room.

Before changing is a good time to head to the toilet to pee. This makes the exam more comfortable.

If the reason for your visit is an annual health check-up it will include a full body exam, starting at your head and usually finishing with the pelvic exam. Please note that you only need one annual exam per year. If you have a complete physical with your midwife or women’s health care provider, you do not need another complete physical with your primary care provider. Most insurance providers cover just one PE a year.

Before the exam begins you should know what to expect, what parts of your body will be examined, and you should be given an opportunity to give permission to have those parts touched. This is your body, and you have agency over it. If you are feeling uncomfortable and you want someone to stop, that is your prerogative, so speak up.

Then comes the time for the gynecological exam. You will be asked to lie down on your back. Some providers like to place women’s feet in stirrups. I avoid using stirrups if I can since they remind me of medieval torture devices. Without stirrups you will need to bend your knees and keep your feet flat on the table.

Since I like my clients to see what I am doing during the exam, and don’t want to give up an educational opportunity, I usually give women the option to hold a small hand mirror during the procedure.

The exam starts with an evaluation of the external genitalia which the provider performs with gloved hands and sometimes a Q-tip. They are assessing for pain, the color and texture of your skin tissue, lumps or signs of infection, and the general health of your vulva: the labia majora and minora, the vaginal opening, the area around your urethra, your perineum, and your clitoris.

The next part is the speculum exam. This is a plastic or metal duck billed looking object that is inserted into the vagina to get a peek at your cervix, the opening of your uterus. If you have the chance to look at it you should, it is really quite cool. They will also inspect the walls of your vagina. From here your provider may take some swabs to test for cancer or infection.

The pap smear test was a test invented in 1928 by Dr. George Papanicolaou (hence the name “pap” smear). It is a screening test for cervical cancer. The rate of cervical cancer has drastically decreased in populations that have access to this test since it was developed. Then in 1956, another scientific breakthrough was made, the isolation of the Human Papilloma Virus, or HPV. There are over 100 different strains of HPV, but in 1984 the scientist Harald zur Hausen discovered that HPV strains 16 and 18 could be attributed to cervical cancer. Through his research and discoveries, new tests, vaccines, and policies were created regarding cervical cancer screening.

So given all this information, here are the cervical cancer screening guidelines, HOT OFF THE PRESS! The latest guidelines from the U.S. Preventive Services Task Force were published on August 21, 2018. This is a group of medical experts who make evidenced based recommendations on preventative tests and procedures to ensure good health for all Americans. We rely on their advice, but changes in guidelines are always happening so be sure to discuss recommendations with your provider to confirm. But for this moment in time, if you are healthy, do not have an immune compromising illness like HIV, and do not have a history of high grade precancerous disease or cervical cancer, and all your testing is normal, you should follow these guidelines:

  • Under 21, no pap smear or HPV screening is recommended (However it is recommended that all boys and girls get the HPV vaccine)

  • Ages 21-29, you should get a pap smear only every three years

  • Ages 30-65 you have a choice: a) pap smear only every three years, b) HPV test only every five years c) pap and HPV test every five years

  • 65 and over, no need for testing if you have a long history of normal pap/HPV screening

  • No pap is necessary if you had a total hysterectomy for a low risk reason

These guidelines must sound a bit complicated. This is further proof that your care needs to be individualized and you need to have a conversation with your provider about what testing is right for you before you have the exam done.

So what else is happening down there? Besides pap smear screening additional swabs can be taken with your permission for sexually transmitted infections including gonorrhea, chlamydia, herpes, and possibly bacterial vaginosis or yeast.

After the speculum is removed, the grand finale of the exam is called a “bimanual exam”. The provider inserts usually two fingers into your vagina and uses the other hand to press around your lower abdomen to feel for your uterus and ovaries, to make sure they are normal size and pain free. You may feel pressure with this exam, but should not feel pain.

At this point an annual exam with a gynecological component is recommended every year however it is unclear if an internal exam is needed every year if you have a history of normal pap smears and do not have any health issues or risks.  

So now you know. You do not have a pap smear test every time you have an internal gynecological exam and you do not need pap smear screening every year. I hope this post will enhance what you know about your body and recommended care to help you get what you deserve.

Susan Kamin Lifecycle Women's Health

Susan Kamin, CNM, MSN, MPH opened Lifecycle Women’s Health in order to provide sensitive and equitable women’s health care in a safe and non-rushed environment. Her focus is on sexual health and well body care for all women from adolescence past menopause. She works in partnership with her clients to achieve optimal wellness by encouraging lifestyle changes and incorporating natural as well as medical remedies as needed.

If I am not addressing topics that are important to you, please let me know and send ideas for future posts. Thanks for visiting!

The first step is the hardest

The first step is the hardest

Welcome to Lifecycle Women’s Health!

Welcome to Lifecycle Women’s Health!